Hindawi Publishing Corporation

Scientifica
Volume 2016, Article ID 5731627, 13 pages
http://dx.doi.org/10.1155/2016/5731627

Research Article
A Mixed Method Research to Identify Perceived Reasons and
Solutions for Low Uptake of Cervical Cancer Screening in Urban
Families of Bhopal Region

Nancy Jain, Ajay Halder, and Ragini Mehrotra

All India Institute of Medical Sciences Bhopal, Madhya Pradesh 462022, India

Correspondence should be addressed to Ajay Halder; ajay.obgy@aiimsbhopal.edu.in

Received 4 December 2015; Accepted 16 March 2016

Academic Editor: Shunsuke Nakagawa

Copyright © 2016 Nancy Jain et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Low uptake of cervical cancer screening is not a matter of poor coverage of health care facilities only. We wish to identify the
perceived reasons behind low uptake of screening in Bhopal region and also possible solutions for an urban setting. In a mixed
research, through a series of focused group discussions, we wished to do thematic interpretation of the perceptions towards cervical
cancer screening by deductive content analysis of FGD and also to obtain a free list of perceived causes and solutions with Smith’s
saliency score and perform cluster analysis by pile sorting. We found that the perceived reasons could be grouped into three themes
which were (1) information gap leading to fear of unknown, (2) casual attitude, and (3) resource constrains and affordability issues. For
the perceived solutions there were 11 codes which could be grouped into two groups; these were increasing awareness and vaccination.
Free list of perceived reasons and solutions has also been generated. No single solution can be suggested but a comprehensive
approach with awareness campaigns, personalized encouragements, affordable and friendly health care with subsidized vaccination,
and screening facilities are expected to increase awareness and acceptability and thus reduce burden of disease in the long run.

1. Introduction where cervical cancer screening is offered as part of routine

Cervical cancer is the third most commonly diagnosed cancer
and the fourth leading cause of cancer death in women
worldwide [1]. Estimated 529,000 new cases and 275,000
deaths occurred in 2008 out of which 79–83% of new cases
were diagnosed in developing countries [2], whereas, in
developed countries, cervical cancer accounts for only 3.6%
of new cancers, with a cumulative risk of 0.8% (age 0 to 64
years) [3].
Cervical cancer is the most common type of cancer in
Indian females aged 15 years and above [1]. With a lifetime
incidence of 1 : 53 (versus 1 : 100 developed regions) 74,000
new cases were diagnosed in 2010 [4]. Since 70% cases are
diagnosed at stage III or IV there is 32% mortality rate, 30%
5-year survival for stage III, and a dismal 6% for stage IV. In
an estimate there will be 225,000 new cases in 2025 [5].
Screening of adult women for cervical cancer and adoles-
cent HPV vaccination can prevent two out of three cervical
cancer deaths [4]. In contrast to high-income countries,
primary care, few large-scale screening programs exist in
India [5]. Moreover, though primary prevention through
human papilloma virus (HPV) vaccination is gaining accep-
tance in high-income countries and has been endorsed by
the World Health Organization (WHO), vaccine awareness,
access, and use are very low in India [6, 7]. Most of the
cervical cancer screening in India is opportunistic and almost
negligible voluntary screening. The District Cancer Control
Program initiated in year 2005 under the National Cancer
Control Policy of Ministry of Health and Family Welfare,
Government of India, strives to achieve larger coverage
of women with early detection and screening through the
exiting health care system at the district level free of cost
[8]. But large-scale community level cervical cancer screening
program outside research settings is nonexisting in India at
present. Guidelines for cervical cancer screening in India
were issued in 2005 [9] which address the two basic chal-
lenges in achieving wider cervical cancer screening coverage
in India. Firstly it outlines the methods of community
2 Scientifica
sensitization and motivation to achieve universal screening
and secondly it advices the use of visual inspection methods
(visual inspection under Lugol’s iodine, VILI; visual inspec-
tion under acetic acid, VIA) instead of cytology to curb the
cost and the need for repeated hospital visits. But lack of
awareness, fear of diagnosis, shying from pelvic examination,
and so forth are important causes which keep even urban
educated women away from voluntary cancer screening.
Over the years with research and deliberation in this field it
is now clear that low uptake of cervical cancer screening not
only is a matter of poor coverage of health care facilities but
also is equally or more importantly due to negative attitude
of women themselves, their families, and to some extent a
general behavior of neglect on the part of service providers
[10]. Consequently it becomes prudent to bring about change
in the perceptions of the stake holders regarding importance
of cervical cancer screening and vaccination.
Through this research, we wish to identify the perceived
reasons behind low uptake of screening among a sample of
urban population and their health care providers in Bhopal
region and also identify possible solutions for an urban
setting.
The aims and objectives of the study can be summarized
as follows:
(1) thematic interpretation of the perceptions of the
women and health care providers towards cervical
cancer screening by deductive content analysis of
focused group discussion (FGD);
(2) obtaining a free list of perceived causes and solutions
of low uptake of cervical cancer screening among
women and their health care providers with Smith’s
saliency score;
(3) making groups of the above listed perceived causes
and solutions with high Smith’s saliency score (cluster
analysis);
(4) obtaining the consensus measure (%) among women
about various issues raised in the questionnaire.
2. Material and Methods
2.1. Study Setting. The study is a community based cross-
sectional mixed method research with both quantitative and
qualitative methods. For qualitative study we conducted
focused group discussion of stake holders followed by deduc-
tive content analysis [11]. And for the quantitative part we
assessed the knowledge, attitude, and practice of women
through a structured questionnaire. To reach out to the target
of cervical cancer screening, study was undertaken at com-
munity level in various blocks of Bhopal which is the capital
city of Madhya Pradesh.
2.2. Participants. In a mixed research, questionnaire based
interviews (quantitative method) and focused group dis-
cussion (qualitative method) were used to understand the
perceived barriers to cervical cancer screeching in the urban
population of Bhopal [12]. Participants were women aged
between thirty and sixty years from urban residential areas
and slums and health care professionals who can possibly
encourage and administer cervical cancer screening like
gynecologist and general practitioners.
2.3. Sampling Method and Sample Size. For the questionnaire,
multistep cluster sampling was done and the sample size was
the number of items in the questionnaire × 10.
For the qualitative research methods we use nonprobabil-
ity sampling method; in this case we used purposive sampling
method. Sample size was taken as the number of cases till
saturation of responses that is where it stops yielding further
new information [13].
2.4. Tool Development. A questionnaire verifying the knowl-
edge, attitude, and practice of the women about present
scenario of cervical cancer screening was developed by the
researcher with dichotomous response (yes or no). After key
informant interview with five gynecologists and 2 women
eligible for cervical cancer screening a draft questionnaire was
developed with 28 items. It was face validated by the experts of
the fields like experienced gynecologists and epidemiologist.
Eight items were removed for poor content validity and
wording of few items was changed for ease of interpretation.
Finally the tool contained 20 items with six items representing
the demographic data with Kuppuswamy socioeconomic
class. Thirteen items verified the “knowledge” of women
towards cervical cancer, its risk factors, and vaccination.
Each item was given a weightage according to its subjective
importance for the laywomen from minimum of 1 to a
maximum weightage of 5. The total score therefore could vary
from a maximum of 38 (100%) and a minimum of 0 (0%). A
score of ≥19 (≥50%) was considered “adequate” and women
with scores ≥ 29 (≥75%) were considered “well aware.” The
“practice” was assessed by the percentage of women who
underwent cervical cancer screening. Before final adminis-
tration the questionnaire was pilot tested on a small sample of
women attending the gynecology outpatient departments in
AIIMS Bhopal Hospital to identify ambiguous wording and
double barreled questions.
2.5. Data Collection. Women with age between 30 and 60
years were approached in a door to door survey by inter-
viewers in four wards of Bhopal city including two organized
residential areas and two slums. After taking informed
consent, women were requested to fill survey questionnaire
developed for the purpose. A purposive sampling of women
who participated in the survey was done and they were
invited for focused group discussion (FGD) in a convenient
time and place in the locality itself. FGD was conducted
face to face by an interviewer trained in qualitative research.
A group of 6 to 8 willing women were asked questions as
per interview guide. A written consent was taken by all
participants. The purpose of the study, the procedure to be
followed, and its implications were explained to all partici-
pants. Proceedings were recorded on audio recorder enabled
mobile phones. A transcript was prepared by the interviewer
soon after finishing the FGD and cross-checked with the
participants for approval. Five such FGDs were conducted
Scientifica 3

with laywomen and four FGDs were conducted with health Table 1: Demographic date of participants of the survey.
care professionals including gynecologist, medical graduates,
and nursing staff. FGDs with different participants were 𝑁 (%)
Total 306
conducted till the saturation of responses was met. Also a
free listing exercise was done to identify major causes of low Age (years)
cervical cancer screening and possible solutions with all the <30 80 (26.14)
FGD participants. Smith’s 𝑆 (Smith’s saliency score) refers to ≥30–40 90 (29.41)
the importance, representativeness, or prominence of items ≥40–50 70 (22.72)
to individuals or to the group and is measured in three ways: ≥50–60 32 (10.45)
word frequency across lists, word rank within lists, and a
≥60 34 (11.11)
combination of these two [14]. Reasons with relatively high
Smith’s 𝑆 value were then pile sorted by equal number of Marital status
participants for cluster analysis. Married 292 (95.42)
Unmarried 14 (4.57)
2.6. Data Analysis. The quantitative data will be analyzed Educational status
using Microsoft Excel 2007 (Washington, USA). Professional 8 (2.61)
A summative approach to qualitative content analysis was
Graduate 122 (39.86)
undertaken to identify and quantify themes from the text
data and infer meaning in the given context [15]. The method SSC 48 (15.68)
suggested by Graneheim and Lundman [16] was adopted. HSC 22 (7.14)
The procedure involved document preparation, open coding, Middle school 46 (15.03)
grouping, categorization, and theme abstraction. Since the Primary school 26 (8.49)
basic outline of the outcome on the study was known due Illiterate 36 (11.76)
to previous studies a deductive content analysis method was
Occupation
used. The units of analysis were women’s and health care
professional’s individual statements. Statements with similar Professional 46 (15.03)
meaning were grouped together until a point was reached Semiprofessional 46 (15.03)
where further collapsing resulted in no loss of qualitatively Clerical, shop owner 34 (11.11)
important information. The data were classified and quan- Skilled worker 10 (3.26)
tified as simple nonhierarchical typology of various for and Semiskilled 38 (12.41)
against perceptions.
Unskilled 40 (13.07)
A multidimensional scaling and hierarchical cluster anal-
ysis was done with pile sort data to get collective picture of Unemployed 92 (30.06)
perceived rationale behind “causes” which the women and Family income (in Rupees)
health care professionals felt went together. The analysis of ≥31,507 54 (17.64)
free list and pile sort data was undertaken using Anthropac 15,754–31,506 70 (22.87)
4.98.1/X software [17]. 11,817–15,753 34 (11.11)
7878–11,816 52 (16.99)
2.7. Ethical Issues. This study was sponsored by the Indian
4727–7877 46 (15.05)
Council for Medical Research (ICMR) through its Short
Term Studentship (STS) program. All the participants of 1590–4726 44 (14.37)
questionnaire survey were provided with the information and ≤1589 6 (1.97)
verbal consent was taken. Written consent was taken for FGD Modified Kuppuswamy socioeconomic class
participants. The information sheet was read out to those who Upper 40 (13.07)
could not read it. None of the participants’ identities was Upper middle 110 (35.97)
revealed in this study report. This study has been approved
Lower middle 38 (12.41)
by the Institutional Human Ethics Committee, All India
Institute of Medical Sciences Bhopal with the Project code Upper lower 116 (37.90)
STS-0048-2015. Lower 2 (0.6)

3. Results
3.1. The Knowledge Attitude and Practice Survey. There were
total 306 women who participated in the questionnaire door
to door survey. Sixty percent of women were below forty years
of age, 95% were married, 65% had education above matric-
ulation, 40% were at least graduated, and 11% were illite-
rate. Table 1 shows the demographic details of the partici-
pants.
The knowledge score based on the survey questionnaire
is presented in Table 2. The median score was 18 with 10 and
26 as the 25th and 75th percentile. Twenty-one percent of
women were well informed with score equal to or above 29
(75%), 25% of women were adequately informed, and 54% of
women were inadequately informed.
The results of the survey are shown in Tables 3 and
4. Regarding the baseline knowledge 87 percent of women
4 Scientifica
Table 2: Knowledge score regarding cervical cancer.
Knowledge attitude and practice score
Median score 18 [10–26 (25th and 75th)]
Insufficiently informed (<19) 53.89% (166/308)
Adequately informed (≥19 to <29%) 24.62% (76/308)
Well informed (≥29%) 21.42% (66/308)
reported that they have heard of cervical cancer. Fifty-six
percent of women know that it is the most common cancer
affecting women. Fifty percent of women thought that this
cancer can affect anyone. But only 38 percent of women could
identify at least one common symptom of cervical cancer.
Options given were abnormal vaginal discharge, abnormal
vaginal bleeding, bleeding after sexual intercourse, and bleeding
after menopause. Only 24% of women could appreciate that
this can be caused by sexually transmitted infections and only
40% of women knew that early age at marriage or child birth
could lead to increased risk of cervical cancer. Although 47%
of women were aware that cervical cancer is preventable, only
34% of women had actually heard of something called screen-
ing for cervical cancer. Only 22% of women knew any centre
where cervical cancer testing could be done. Only 11 percent
of women reported to have undergone cervical cancer screen-
ing. Twelve percent of women knew that a vaccine existed
against cervical cancer. At the present cost 30% women
agreed that they would get themselves and their family
vaccinated but 45% women were not sure as to whether they
will be able to get the vaccination done in the present price.
3.2. Results of the Analysis of Focused Group Discussion. There
were eight separate focused group discussions of different
locations, five with laywomen and three with health care
professionals. There were total of 50 participants with 32
women and 18 health care professionals. Figure 1 shows the
scheme of distribution of participants. There were nineteen
codes generated for the baseline knowledge and perceptions
regarding cervical cancer, its symptoms, and risk factors.
There were 23 codes generated for the perceived reasons for
low uptake of cancer screening. These codes were grouped
into three themes which were (1) information gap leading
to fear of unknown, (2) casual attitude, and (3) resource
constrains and affordability issues each containing eight, five,
and ten codes, respectively. For the perceived solutions there
were 11 codes which were grouped into two groups; these
were increasing awareness and vaccination with five codes
each. Table 5 shows the thematic analysis of the focused group
discussions and the categorization matrix.
Content Analysis of Focused Group Discussion. The following
are the category, subcategory, and code wise content analysis
which are numbered in the paragraph separated by dots.
Same numbers could be referred to in Table 5 for better
understanding.
(1.1.1) Women are of the general view that there is gross
lack of awareness about cervical cancer. They perceived it to
be the most common cancer among women along with breast
cancer. The general perception is that women should undergo
306
questionnaire participants
Purposive sampling
6 6 8 6 6
women women women women women
8 focused group discussions with 50 participants
6 6 6
health care health care health care
professionals professionals professionals
Purposive sampling of health care professionals
Figure 1: Scheme of recruitment of participants.
screening regularly as it is a preventable disease. If treatment
is delayed the outcome is more dreaded.
(1.2.1) Regarding the causation of cervical cancer women
perceived white vaginal discharge, heavy and irregular bleed-
ing, pain, and itching in private parts to be important symp-
toms of cervical cancer. Interestingly women were well aware
of the fact that sexually transmitted diseases involving uterus
and related structures caused cervical cancer. In this effect
many emphasized that use of condoms can prevent cervical
cancer. Tobacco consumption is perceived as a causative
factor.
(1.2.2) Author noted that women perceived abdominal
mass including fibroids and ovarian cysts to be important
causes of cervical cancer. Many said that decreased bleeding
may lead to collection of blood inside the uterus and in turn
cause cancer. Unhygienic practices like using dirty linen as
sanitary pads during menstruation by young girls of poorer
section can cause cervical cancer. Other misconceptions
perceived by women to be a causative factor in cervical cancer
were surgical abortions and prolapsed uterus and even not
wearing undergarments was also thought to be a predisposing
factor to infection and thus cervical cancer.
(2.1.1) It was strongly felt that there is lack of awareness
about cervical cancer especially among women from rural
areas. Illiteracy was the principle cause of lack of awareness
and the desire to know about health related issues and
opportunities. This leads to fear of cancer, fear of diagnosis,
and fear of procedures or surgeries. No effort is made on
the part of government to spread awareness about cervical
cancer in particular. Since it is a common life-threatening
Scientifica 5

Table 3: Survey results I.

𝑁 (%)
Baseline knowledge about symptoms and risk factors of cervical cancer
Total 308
Ever heard of cervical cancer (Yes) 87.01% (268/308)
Source of information if heard of cervical cancer
Health care provider 76 (24.68)
Family or relatives 66 (21.43)
Media 60 (19.48)
Friends 66 (21.43)
Not heard 40 (14.98)
Cervical cancer is the most common female reproductive cancer 172 (55.84)
All women are at risk of cervical cancer? 156 (50.65)
Do you know someone with cervical cancer? 90 (29.22)
Are you aware that the following symptoms are associated with genital cancer? (full marks even if one or
118 (38.31)
more is known)
Abnormal vaginal discharge
Abnormal vaginal bleeding
Bleeding after sexual intercourse
Bleeding after menopause
Are you aware that cervical cancer is caused by a sexually transmitted disease? 74 (24.03)
Are you aware that being very younger at marriage and at the time of birth of first child makes women at
126 (40.91)
risk of cervical cancer?

Table 4: Survey result II.

Baseline knowledge of available preventive measures

Are you aware that Cervical cancer can be prevented? 146 (47.40)
Have you heard of cervical cancer testing? 106 (34.42)
Have you heard of center(s) that do cervical cancer testing? 70 (22.73)
If heard of testing then have you ever undergone cervical cancer testing? 34 (11.04)
Are you aware there is a vaccine which can significantly reduce chances of cervical cancer? 40 (12.99)
The cost of vaccination is Rs. 3000/vaccine and three such vaccines are required. Will you like to get
yourself vaccinated if the services are available locally at this cost?
Yes 122 (39.61)
No 48 (15.58)
Not sure 138 (44.81)

disease more efforts should be made by the government
in its prevention. For example, polio could be eradicated
only because of widespread awareness and door to door
availability of vaccination.
(2.1.2) It is perceived by the participants that women in
general lack desire to give importance to personal health
related issues. They take their health related issues casually
and deny the fact that they can ever get the disease. They
even neglect early symptoms and postpone the treatment
till it is late. They find themselves busy with family chores
most of the time. A lot depends on the family members like
husband, mother-in-law, and father-in-law as their concur-
rence is desirable before any attempt is made to get medical
advice.
(2.1.3) When asked to share their experiences and per-
ceptions about health care facilities women unanimously
expressed their unhappiness over the lack of facilities, staff,
and infrastructure in government hospitals. Long waiting
queue and lengthy procedural delays are common. Bad
behavior of doctors and nurses add to the agony. Lack
of punctuality is also perceived as an important reason of
trouble women face in government hospitals. Some women
expressed that the level of satisfaction felt after visiting a gov-
ernment facility is poor and also the diagnosis and treatment
provided by doctors are unreliable. Although women feel sat-
isfied after visiting private facilities they also emphasize that
high cost of treatment precludes its use because most of the
people in India are poor. Few women said that private hospital
do hysterectomy at a trivial complaint without giving any
option for cancer screening or any information about it. They
felt presence of male doctors to be a cause of hesitation to
visit hospital facilities particularly for examination of private

Table 5: Thematic analysis of FGD with categorization matrix.
Category Subcategories
(1) Perceptions about cervical cancer
(1) Baseline knowledge
(2) Perceptions about the causation of cervical cancer
(1) Information gap leading to fear of unknown
(2) Casual attitude
(2) Perceived reasons for low uptake
(3) Resource constrains and affordability issues
6
Codes
Women lack of knowledge about cervical cancer (4)
It is a very common cancer
Cervical cancer is an preventable disease
Every women should be screened
Very few women undergo test
Delay in treatment is associated with poor outcome
White discharge is an initial manifestation (5)
STD of uterus and related structures cause cervical cancer (2)
Use of condoms can prevent cancer (2)
Women having multiple sex partners have more risk of cervical cancer (3)
Irregular periods and heavy periods are associated with cervical cancer (4)
Pain and itching in private parts can be associated with cervical cancer
Abdominal mass and weight gain are symptoms of cervical cancer (2)
Decreased bleeding can be associated with cervical cancer
Unhygienic practices like use of dirty sanitary napkins cause cervical cancer
Surgical abortion can cause cervical cancer
Tobacco consumption is associated with cervical cancer
Prolapsed uterus can cause cervical cancer
Not wearing undergarments can be associated with cervical cancer
Lack of awareness about cervical cancer and screening procedures (5)
Illiteracy among females
Fear of cancer diagnosis (2)
Fear of dropping social image (2)
Fear of procedure (2)
Talking about sex is a taboo
No formal sex education by parents results in unsafe sex practices
No attempt to spread awareness about cervical cancer specially in rural areas (2)
They can never develop cervical cancer (3)
They take personal problems casually
They are busy in daily chores
There is lack of family support
They need permission from family
Long waiting queue and procedural delays in government hospitals (6)
Bad behavior of doctors and staff (2)
Unreliable diagnosis in government hospitals
Poor satisfaction in government hospitals
Nonavailability of doctors and staff in government hospitals (2)
Being hesitant if doctor is male (4)
Lack of cheap public transport
High cost in private hospitals
Women undergo hysterectomy for trivial complaints
Preferring to get screening done in camps
Scientifica
 Scientifica

Table 5: Continued.
Category Subcategories Codes
Seminars for lay public (3)
Television and pamphlets (4)
Doctors should impart knowledge
(1) Increasing awareness
Group discussions among women
ASHA worker can spread (2) awareness in rural areas
Camps by Anganwadi workers
(3) Perceived solutions
Never heard of it
Have heard something but not sure
Would like to accept it is made available
(2) Vaccination
Would like to get the daughters vaccinated
Worried about high cost
Vaccine in for mental satis faction and nothing else
Numbers written after the codes represent the frequency with which the code appeared in FGDs.
7
8 Scientifica
parts. But once they have a problem or surgery is required
they do not hesitate to visit male doctors. Some women
expressed concern about nonavailability of proper transport
to large government hospitals. It takes a lot of money to use
private vehicles to reach there, said one woman. They sug-
gested that they would go to camps by government doctors if
held in nearby places.
(3.1.1) When asked about the most effective ways of
increasing awareness about cervical cancer women expressed
that they have been exposed to home to home surveys
and seminars by nearby nursing college students regarding
various health related issues. And they found it to be enrich-
ing and effective. Therefore, they perceived home visits and
seminars by health professionals as one of the most effective
methods. Moreover they also felt that unless the information
is imparted by doctors or other related health professionals
they ought to be trivialized and undermined. For medical
students they felt the students are actually taking their help in
their studies but they do not mind talking to them as women
themselves also benefit from it.
(3.1.2) Television was perceived to be another important
method which could increase the awareness. This is the
most effective way for illiterate women who cannot read
newspapers or magazines and write. Moreover television sets
are available in many households even in rural areas. Short
films and educational advertisements in between television
serials will be very effective. It is not only informative to them
but also useful for them to convince their husbands for taking
up measures. Short films during interval in film theaters will
be useful in educating youngsters.
(3.1.3) Information notes on newspapers, magazines,
hoardings, and paper pamphlets were suggested by women
to be important methods. Slogans and information printed
on important documents like rail and bus tickets and so forth
could be readily assessed and read.
(3.1.4) Women felt that they can gain from discussion
themselves. A group of women said they gathered for yoga
in a community centre where they discuss several issues
including health related issues. They gain from each other’s
knowledge. Women expressed that ASHA or Anganwadi
workers could participate in such group discussions and
increase awareness of the women of the locality. They can
alleviate their anxiety about the procedures to be undertaken,
cost implications, and so forth.
(3.1.5) Women expressed their unhappiness over lack of
attention given to them by doctors when they visit hospitals.
They considered the information imparted by the doctors
during medical visits to be very useful and effective in behav-
ior change. Women wished that the problem of crowded
hospitals and insufficient staff should not come in their way
in getting full attention from their doctors.
(3.2.1) The general expression of women regarding the
HPV vaccine is that they “never heard about” or “they heard
something but not sure what it is” when the vaccine and its
efficacy are explained to them; they said they “would like to
accept if made available” although they felt worried about the
high cost. They expressed their concern that with the present
cost the poor will never be able to get their girls vaccinated,
more so if a family has more than one girl. If the cost of the
2
1
12
4
8
8 18
7
9 6
5
11
10
Figure 2: Cluster analysis of perceived reasons of low uptake.
vaccine is reduced they would want their daughters to be
vaccinated.
Results of Free Listing and Cluster Analysis. In order to
bring more objectivity and reliability the free listing exercise
was done for the causes of low uptake and their perceived
solutions. There were seventeen participants in the free listing
exercise. Each of them enlisted a set of 2 to 6 causes which
they thought were important in the decreasing order of
significance. “Lack of information about cancer” and “feel shy
to discuss” emerged as the most commonly perceived barriers.
Others were “no attention to personal problems,” “high cost
of treatment,” and “fear of cancer” in the decreasing order of
importance. Table 6 shows the result of free listing exercise.
A multidimensional scaling and hierarchical cluster anal-
ysis was done with pile sort data to get collective picture
of perceived rationale. There were 15 participants in the
pile sorting exercise including both health care professionals
and laywomen. The results of pile sorting are shown in
Figure 2 and Table 7. The three groups which emerged during
cluster analysis show concurrence with the findings of the
thematic analysis of FGDs. These groups were thus named (1)
information gap leading to fear of unknown, (2) casual attitude,
and (3) resource constrains and affordability issues.
With the pile sorted data and its outcome in three major
clusters or groups health care professionals and women
were approached again to enlist solutions for the barriers
separately for each of the three groups. Seventeen participants
deliberated separately to generate separate list of solutions for
each of the groups. The lists of solutions for each group thus
received were free listed again for bringing objectivity and
reliability. Tables 8, 9, and 10 show the results of the free listing
exercise for each of the three groups of barriers. Figure 3
shows the overview of the perceived reasons and solutions for
low uptake of cervical cancer screening.
4. Discussion
The participants of the study were predominantly young with
almost 55% of women below 40 years old. Eleven percent of
women were illiterate and over 40% of women were graduates
or older. According to the Kuppuswamy classification of
socioeconomic class the majority seems to be a mix of two
classes almost of equal proportion, that is, upper middle class
Scientifica 9

Table 6: Free listing of perceived reasons of low uptake.

Item number Perceived reasons Frequency (%) Average rank Salience

1 Lack of information about cancer 88.2 1.6 0.725
2 Feel shy to discuss 64.7 2.09 0.461
3 No attention to personal problems 35.3 1.83 0.301
4 High cost of treatment 23.5 3 0.136
7 Fear of cancer 17.6 2.33 0.113
5 Busy schedule 23.5 3.5 0.09
6 Lack of family support 17.6 2.67 0.078
8 Fear of procedure 11.8 2.5 0.074
10 Denial, they think they would not contract disease, so they do not go for screening 11.8 3 0.059
9 Do not seek treatment unless symptomatic 11.8 4 0.045
11 Poor facilities in government hospital 5.9 6 0.017
12 Lack of information about screening procedures 5.9 5 0.012
13 Costly treatment at private setup 5.9 7 0.008

Table 7: Clustering of perceived reasons for low uptake of cervical cancer screening.

Reasons of low uptake Groups

1 Lack of information about cancer
2 Feel shy to discuss
7 Fear of cancer Informational gap leading to fear of unknown
8 Fear of procedure
12 Lack of information about screening procedures
3 No attention to personal problems
5 Busy schedule
6 Lack of family support Casual attitude
9 Do not seek treatment unless symptomatic
10 Denial, they think they would not contract disease
4 High cost of treatment
11 Poor facilities in government hospital Resource constraints and affordability issues
13 Costly treatment at private setup

Table 8: Perceived solutions for “information gap leading to fear of the unknown.”

Perceived solutions Frequency (%) Average rank Salience

(i) Awareness camps at community level 80 1.25 0.742
(ii) Mass media (print media) 53.3 2.38 0.328
(iii) Mass media (advertisements on television) 40 2.17 0.267
(iv) Educational street plays 20 2 0.139
(v) Information printed behind common commodities 20 2.33 0.122
(vi) Organizing group discussions 20 3.33 0.069
(vii) Educational camps in schools 13.3 2 0.103
(viii) School students led to home to home awareness 6.7 5 0.013
(ix) Counseling centers at community level 6.7 2 0.033
(x) Announcements at public places 6.7 4 0.017
(xi) Free screening at gynecology OPD 6.7 2 0.033
(xii) Doctors should educate about screening 6.7 3 0.033
(xiii) CHW led to home to home spread of awareness 6.7 4 0.027
10 Scientifica

Table 9: Perceived solutions for “casual attitude.”

Perceived solutions Frequency (%) Average rank Salience
(i) Increasing awareness about cancer 73.3 1.27 0.65
(ii) Counseling husband and other family members 40 1.5 0.322
(iii) Family physicians should counsel the lady and 13.3 1.5 0.111
family
(iv) Group counseling at work places 6.7 3 0.033
(v) Government can offer monetary grant for first 6.7 4 0.017
screening
(vi) Acknowledging that every lady is susceptible 6.7 2 0.044
(vii) Door to door provision of screening and 6.7 1 0.067
vaccination
(viii) Free screening at OBGY OPD 6.7 3 0.022
(ix) Educating young females and encouraging them to 6.7 1 0.067
spread awareness among their relatives and friends

Table 10: Perceived solutions for “resource constrains and affordability issues.”

Perceived solutions Frequency (%) Average rank Salience

(i) Subsidized treatment for BPL card holders 40 1.5 0.328
(ii) Free screening camps 26.7 1.5 0.2
(iii) Increasing staff and equipment in government 26.7 2 0.189
hospitals
(iv) Subsidized vaccine for BPL card holders 20 1 0.2
(v) Separate screening OPDs at every government 13.3 3 0.044
hospital
(vi) Mass vaccination at low cost 13.3 1.5 0.1
(vii) Provision for screening at primary health centers 13.3 1 0.133
(viii) Training nurses especially for Pap smear 13.3 3.5 0.039
(ix) ASHA and USHA workers trained to do screening 6.7 1 0.067
at village
(x) Self-screening kits can be developed 6.7 2 0.044
(xi) Allowing payment of vaccine in installments 6.7 2 0.033
(xii) Discounted treatment by pharmaceutical 6.7 2 0.033
companies
(xiii) Government schemes to promote cancer 6.7 2 0.044
screening at every level
(xiv) Health camps aiming at high-risk population 6.7 1 0.067
(xv) Certain days of the year should be allotted for
cervical cancer screening on a mass scale (like pulse 6.7 3 0.022
polio)
(xvi) Government policies for cost control in private 6.7 3 0.022
hospitals
(xvii) Educating about low cost of screening and 6.7 1 0.067
treatment at government hospitals

(36%) and upper lower class (39%). This can be explained by
the choice of conducting survey, that is, two urban slums and
two well planned housing colonies. In the knowledge attitude
and practice section of the study which was done through
the structured questionnaire, the average knowledge of the
section of women interviewed was 18/39 (46.15%) which was
below adequate as preset in the questionnaire, that is, 50%.
Moreover more than 53.97% of women had their knowledge
score below adequate, that is, 19. This population seems to be
doing better in terms of baseline knowledge as far as other
studies [18, 19] are concerned which measure maximum up to
20% only having adequate knowledge. This observation can
be explained by the fact that the questionnaire was designed
by the author to measure the knowledge of women sufficient
enough to understand the importance of screening and not to
gain in-depth knowledge of cervical cancer. Women below 40
years of age have significantly lower mean knowledge scores
(16.38 versus 18.46; 𝑝 = 0.05). This difference seems starker
Scientifica 11

Perceived barriers to low uptake of cancer screening

Lack of information about cancer No attention to personal problems High cost of treatment
Feel shy to discuss Busy schedule Poor facilities in government
Fear of cancer Lack of family support hospital
Fear of procedure Do not seek treatment unless Costly treatment at private setup
Lack of information about screening symptomatic
procedures Denial, they think would not
contract disease

Informational gap Resource constraints and

leading to fear of Casual attitude
affordability issues
unknown

Awareness camps at community level
Mass media (print media)
Mass media (advertisements on
television)
Educational street plays
Information printed behind common
commodities
Increasing awareness about cancer
Counseling husband and other family
members
Family physicians should counsel the
lady and her family
Subsidized treatment for BPL card holders
Free screening camps
Increasing staff and equipment in hospitals
Subsidized vaccine for BPL card holders
Separate screening OPDs at every hospital
Mass vaccination at low cost
Provision for screening at PHCs

Perceived solutions for increasing uptake of cancer screening

Figure 3: Overview of perceived barriers and their solutions.

when the number of illiterate women is significantly more
in the older group (14/170 versus 22/138; 𝑝 < 0.036). There
is no significant difference in socioeconomic class among
women of the two age groups either to explain the above
finding (𝑝 > 0.05). This could be rather understood by the
fact that the knowledge about cervical cancer screening is
acquired through real life exposure to health care facilities
which older women seem to have more experience with.
This is independent of their exposure to formal educational
system. Almost 88% of women had heard of cervical cancer
but the source of information does not seem to show any
predilection to particular method and equally distributed
among the sources of information like media, health care
professionals, friends, and family. Only 29% of women could
identify at least one symptom of cervical cancer and only 24%
women knew that it could be caused by sexually transmitted
disease. These findings are similar to observations on a cross-
sectional study [19] conducted in hospital settings in the same
area. Regarding the knowledge of preventive measures and
screening, the performance is dismal as shown in previous
studies [18, 20, 21]. Although almost half of the women
think that cervical cancer is a preventable disease only 34%
of women know about cervical cancer screening and only
dismal 11 percent of women have ever undergone test [18, 19].
About the vaccine availability 13% of women agreed that they
know about the vaccine. This percentage seems to be higher
than that shown in other studies [19]. When asked about
whether they would like to get vaccinated or their daughters
vaccinated only 39.60% of women agreed in the same cost.
The fight against cervical cancer is the fight against human
perceptions and misconceptions. Even with the availability
of cost effective easily available methods we have not been
able to increase the acceptance of cervical cancer screening.
Lack of will of the government, the family members, and
the women themselves stems from various sociocultural and
economic barriers. Qualitative studies have been shown to
be helpful in revealing the caveats of human perception and
thus devise strategies against them. Qualitative methods have
been used now for a long time to understand the barriers
against reducing cervical cancer deaths and disease burden.
Present study attempted to understand the perceptions of
the stakeholders regarding cervical cancer and inquire into
possible solutions. Inclusion of both the beneficiaries and
health care professionals’ perceptions makes this study more
comprehensive and widely applicable.
Women strongly perceive that the awareness about cer-
vical cancer is low and needs to be enhanced. They correctly
and consistently identify few early symptoms as well as risk
factors of cervical cancer. They also are carrying several
misconceptions regarding cervical cancer like the fact that
not wearing undergarments or prolapsed uterus or decreased
menstrual bleeding or surgical abortions can cause cervical
cancer. The knowledge about HPV vaccination is very low
but women stated that they would like to get their daughters
vaccinated if it is available easily at an affordable cost.
The three main themes which emerged from the content
analysis about the perceived reasons of low cervical cancer
screening are (1) information gap leading to fear of unknown,
12
(2) casual attitude, and (3) resource constrains and affordabil-
ity issues.
“Information gap leading to fear of unknown” seems to
be the most strongly felt perception of women which they
consider as barrier to proper utilization of screening facility.
“Lack of awareness among females” and “illiteracy among
females” were frequently quoted sentences during interview.
Other researchers [8, 22] also found this factor to be the
most important cause where they have quoted it as “ignorance
about cancer,” “cultural constructs/belief about illness,” and
“low knowledge levels.” In the free listing exercise women
enlisted the causes as “lack of information about cancer,” “feel
shy to discuss,” “fear of cancer,” “fear of procedure,” and “lack
of information about screening procedure,” in that order. The
perceived solution to these barriers is obviously to indulge
in activities which increase awareness. This can be largely
summarized into three approaches. (a) Awareness camps in
community level, (b) use of electronic or print media, and (c)
finally opportunistic counseling by health care professionals.
“Casual attitude” is probably the most poorly understood
theme of the entire phenomenon. Distinct from lack of aware-
ness, casual attitude stems from issues of gender equality,
deprivation of reproductive rights of women, and incapability
to take decisions. Deeply ingrained in the society these norms
have caused oppression of women in our society to look
so natural and devoid of malintention. Women also tend to
live with the reality and develop compensatory explanations
which mainly appeared in these interviews like “they are
busy in daily chores,” “they can never develop cancer,” “they
need permission from family,” and so on. Solutions to casual
attitude as a hindrance to reduced uptake of cervical cancer
are multipronged with merging boundaries as the problem
itself. Deduction of the solution as suggested by participants
can largely be of two types: first is a personalized counseling
of the women and family and second is easy access to services.
Personalized counseling is in the form of counseling by family
physicians, peer help groups, work place counseling sessions,
and inclusion of husband and other family in counseling.
The second aspect of easy access to services can be done
by monitory grants for first screening and free screening in
government hospitals and subsidized in private ones.
“Resource constraints and affordability issues” are the most
widely deliberated issue. “Long waiting queues and proce-
dural delays,” “bad behavior and attitude of doctors and staff,”
“unreliable diagnosis in government hospitals,” “poor satisfac-
tion in government hospitals,” and “nonavailability of staff ”
were the main expressions which we encountered. Other
researchers [22–24] named these as “economic factors”;
“unfriendly health care services,” “large number of patients,”
“lack of infrastructure and medical supplies,” and “lack of
policy guidelines” are among the important ones. The solution
to this problem is strengthening the present infrastructure
with equipment, use of low cost modern technology, and
above all dedicated trained staff who can work at the primary
care level. The suggestion included “training of ASHA workers
and staff nurses,” “dedicated screening clinics in hospital
which are hassle-free and free of cost,” “free screening camps,”
“subsidized vaccination for poor sections of the society,” and
“development of screening methods which patients themselves
Scientifica
can do.” Most importantly, the need for development of
national policy of guideline for cervical cancer screening and
infrastructure requirement for the same is felt.
5. Conclusion
The perceived reasons for low uptake of cervical cancer
screening in the society are largely “low felt need” arising
from lack of awareness. In order to reduce the burden of
cervical cancer morbidity and mortality due to late diagnosis
widespread awareness campaign using multimedia and per-
sonalized encouragement by health care professionals at com-
munity level and in hospital settings will be effective. Efforts
should be made so that the health care facilities reach the
masses in an affordable and friendly manner. Subsidized vac-
cination against HPV and newer self-administered screening
tests are areas which should be given more attention in future.
Competing Interests
The authors declare no conflict of interests.
References
[1] Institute for Health Metrics and Evaluation, The Challenge
Ahead: Progress in Breast and Cervical Cancer, Institute for
Health Metrics and Evaluation, Seattle, Wash, USA, 2011.
[2] J. Varughese and S. Richman, “Cancer care inequity for women
in resource-poor countries,” Reviews in Obstetrics and Gynecol-
ogy, vol. 3, no. 3, pp. 122–132, 2010.
[3] M. I. Shafi, H. M. Earl, and L. T. Tan, Gynaecological Oncology,
Cambridge University Press, New York, NY, USA, 2nd edition,
2010.
[4] S. J. Goldie, C. Levin, N. R. Mosqueira-Lovón et al., “Health
and economic impact of human papillomavirus 16 and 18
vaccination of preadolescent girls and cervical cancer screening
of adult women in Peru,” Revista Panamericana de Salud
Pública, vol. 32, no. 6, pp. 426–434, 2012.
[5] E. Vallikad, “Cervical cancer: the Indian perspective,” Interna-
tional Journal of Gynecology and Obstetrics, vol. 95, supplement
1, pp. S215–S233, 2006.
[6] M. Jacob, N. Mawar, L. Menezes et al., “Assessing the envi-
ronment for introduction of human papillomavirus vaccine in
India,” Open Vaccine Journal, vol. 3, no. 1, pp. 96–107, 2010.
[7] P. Madhivanan, K. Krupp, M. N. Yashodha, L. Marlow, J. D.
Klausner, and A. L. Reingold, “Attitudes toward HPV vacci-
nation among parents of adolescent girls in Mysore, India,”
Vaccine, vol. 27, no. 38, pp. 5203–5208, 2009.
[8] V. K. Fort, M. S. Makin, A. J. Siegler, K. Ault, and R. Rochat,
“Barriers to cervical cancer screening in Mulanje, Malawi: a
qualitative study,” Patient Preference and Adherence, vol. 5, pp.
125–131, 2011.
[9] National Cancer Control Programme Guidelines, Ministry of
Health and Family Welfare, Government of India, 2005, http://
www.mohfw.nic.in/showfile.php?lid=325.
[10] Guidelines for Cervical Cancer Screening Programme, National
Cancer Control Programme, New Delhi, India, 2005, http://
screening.iarc.fr/doc/WHO India CCSP guidelines 2005.pdf.
[11] S. Elo and H. Kyngäs, “The qualitative content analysis process,”
Journal of Advanced Nursing, vol. 62, no. 1, pp. 107–115, 2008.
Scientifica 13

[12] P. M. Hudelson, Qualitative Research for Health Programmes,

World Health Organization, Geneva, Switzerland, 1994.
[13] M. N. Marshall, “Sampling for qualitative research,” Family
Practice, vol. 13, no. 6, pp. 522–525, 1996.
[14] R. W. Schrauf and J. Sanchez, “The preponderance of negative
emotion words in the emotion lexicon: a cross-generational and
cross-linguistic study,” Journal of Multilingual and Multicultural
Development, vol. 25, no. 2-3, pp. 266–284, 2004.
[15] H.-F. Hsieh and S. E. Shannon, “Three approaches to qualitative
content analysis,” Qualitative Health Research, vol. 15, no. 9, pp.
1277–1288, 2005.
[16] U. H. Graneheim and B. Lundman, “Qualitative content analysis
in nursing research: concepts, procedures and measures to
achieve trustworthiness,” Nurse Education Today, vol. 24, no. 2,
pp. 105–112, 2004.
[17] S. Borgatti, ANTHROPAC (Computer Program), Version 4.98.1/
X, Analytic Technologies, Natick, Mass, USA, 1998.
[18] J. Shrestha, R. Saha, and N. Tripathi, “Knowledge, attitude and
practice regarding cervical cancer screening amongst women
visiting tertiary centre in Kathmandu, Nepal,” Nepal Journal of
Medical Sciences, vol. 2, no. 2, pp. 85–90, 2013.
[19] A. B. Bansal, A. P. Pakhare, N. Kapoor, R. Mehrotra, and A. M.
Kokane, “Knowledge, attitude, and practices related to cervical
cancer among adult women: a hospital-based cross-sectional
study,” Journal of Natural Science, Biology and Medicine, vol. 6,
no. 2, pp. 324–328, 2015.
[20] E. Singh, S. Seth, V. Rani, and D. K. Srivastava, “Awareness of
cervical cancer screening among nursing staff in a tertiary insti-
tution of rural India,” Journal of Gynecologic Oncology, vol. 23,
no. 3, pp. 141–146, 2012.
[21] M. Singh, R. Ranjan, B. Das, and K. Gupta, “Knowledge, attitude
and practice of cervical cancer screening in women visiting a
tertiary care hospital of Delhi,” Indian Journal of Cancer, vol. 51,
no. 3, pp. 319–323, 2014.
[22] T. Mutyaba, E. Faxelid, F. Mirembe, and E. Weiderpass, “Influ-
ences on uptake of reproductive health services in Nsangi
community of Uganda and their implications for cervical cancer
screening,” Reproductive Health, vol. 4, article 4, 2007.
[23] Z. M. Chirenje, S. Rusakaniko, L. Kirumbi et al., “Situation ana-
lysis for cervical cancer diagnosis and treatment in east, central
and southern African countries,” Bulletin of the World Health
Organization, vol. 79, no. 2, pp. 127–132, 2001.
[24] L. W. Kivuti-Bitok, G. P. Pokhariyal, R. Abdul, and G. McDon-
nell, “An exploration of opportunities and challenges facing
cervical cancer managers in Kenya,” BMC Research Notes, vol.
6, article 136, 2013.

The Scientific
World Journal
Hindawi Publishing Corporation
http://www.hindawi.com
Journal of
Immunology Research
Hindawi Publishing Corporation
http://www.hindawi.com
PPAR Research
Hindawi Publishing Corporation
http://www.hindawi.com
Journal of
Ophthalmology
Hindawi Publishing Corporation
http://www.hindawi.com
Computational and
Mathematical Methods
in Medicine
Hindawi Publishing Corporation
http://www.hindawi.com
MEDIATORS of
INFLAMMATION
Gastroenterology Journal of
Research and Practice
Hindawi Publishing Corporation
Hindawi Publishing Corporation
Diabetes Research
Hindawi Publishing Corporation
Disease Markers
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014
Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014
International Journal of
Endocrinology
Hindawi Publishing Corporation
Volume 2014 http://www.hindawi.com Volume 2014
Submit your manuscripts at
http://www.hindawi.com
BioMed
Research International
Hindawi Publishing Corporation
Volume 2014 http://www.hindawi.com Volume 2014
Journal of
Obesity
Evidence-Based
Stem Cells Complementary and Journal of
International
Hindawi Publishing Corporation
Alternative Medicine
Hindawi Publishing Corporation Hindawi Publishing Corporation
Oncology
Hindawi Publishing Corporation
Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014
Parkinson’s
Disease
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation
Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014